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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

26 Approval Date: representatives from the Bureau of Health Immunization Program and WIC Program. On an annual basis, staff from the Bureau of Health conduct medical record reviews on a sampling of children enrolled in MaineCare to assess immunization rates and report to the CMS GPRA project director on MaineCare’s immunization rate for children from birth to age 2. Information from the sampling is combined with the claims data to create a hybrid rate and determine appropriate interventions, e.g., public service announcements and other forms of advertising stressing the importance of immunizations for all appropriate age groups.

Another group, the Benefits for Members Under 21 Committee, meets periodically and is comprised of staff from the Bureau of Medical Services and Bureau of Health child-related programs such as: WIC, Public Health Nursing, Oral Health, and the Teen and Young Adult Health. The purpose of the group is to coordinate outreach and planning activities for promoting access to services across all programs.

7.1.2

Performance measurement

The Bureau uses two primary means of monitoring and providing feedback to providers regarding performance: a Utilization Report and the Primary Care Physician Incentive Payment report. The Utilization Report is distributed to primary care physicians at least twice a year and contains 22 performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention measures. The report, broken down by specialty, presents a comparison of each primary care physician against other statewide providers across all performance measures. The Primary Care Physician Incentive Payment report contains additional performance measures focused on preventive indicators and is used for purposes of provider education and determining incentive payments.

The Bureau has also developed an incentive program designed to improve health outcomes through management of drug utilization. The Physician Directed Drug Initiative provides incentive payments to providers based on measures of peer performance for certain relevant desired drug outcomes/medical conditions (e.g., increase in percentage of CAHF patients on ACEI); peer performance for medical outcomes related to these medical conditions (e.g., maintain/reduce hospital/ER visits for CAHF patients); and peer performance for medical outcomes across all medical conditions aggregated together (e.g., total hospitalization rates, length of stay, readmission rates/ER rates).